Stockholm City’s Elderly Care and Covid19

Upwards of 70 percent of the Covid19 death toll in Sweden has been people in elderly care services (as of mid-May 2020). We summarize the Covid19 tragedy in elderly care in Sweden, particularly in the City of Stockholm. We explain the institutional structure of elderly care administration and service provision. Those who died of Covid19 in Stockholm’s nursing homes had a life-remaining median somewhere in the range of 5 to 9 months. Having contextualized the Covid19 problem in City of Stockholm, we present an interview of Barbro Karlsson, who works at the administrative heart of the Stockholm elderly care system. Her institutional knowledge and sentiment offer great insight into the concrete problems and challenges. There are really two sides the elderly care Covid19 challenge: The vulnerability and frailty of those in nursing homes and the problem of nosocomial infection—that is, infection caused by contact with others involved in the elderly care experience. The problem calls for targeted solutions by those close to the vulnerable individuals.

That is the abstract of a new paper by Charlotta Stern and Daniel B. Klein.

Comments

The Swedish model ends up looking pretty much like the Fairfax model - a significant number of dead old people, with an economy that was heavily impacted by the pandemic.

Skoal.

This is also Captain Bolsonaro's strategy. Great minds think alike.

Today is Memorial Day 2020, a fitting date to remember the 100,000 Americans that have died from this pandemic. Does it matter what their age is?

Nursing home status only matters if one is interested in targeting measures to actually be effective in preventing such deaths.

That no one at MR talks about the German model then. Sweden has done little better to date than France in terms of deaths per million, whereas Germany has a quarter of their deaths. One country has had a major outbreak (though effectively contained at this point) without the large number of deaths that one sees in a country like Sweden or the U.S.

There is a stereotype that I believe has some truth to it, that as a group, the Germans tend to be extremely attentive (some would say obsessively so) to order, cleanliness, and questions of contagion and contamination. If so, there may be cultural tendencies in place that make it easier and more natural to implement behavioral changes that would be effective in spreading disease; and, in fact, the baseline patterns of life may be such that R would be lower in any case, and perhaps also a different pattern of relationship between R and k.

Correction: should have read: "...that would be effective in preventing the spread of disease..."

It is a mistake to make these comparisons so early in the spread of this virus. 12 months from now it is likely that few places will be untouched and it is likely that deaths per capita will be much closer to equal across the board. Except for NY City of course where the stupid leaders did stupid/criminal things.

No, it is not the least bit fitting to conflate this pandemic with Memorial Day, especially when many Americans are confused about what Memorial Day serves to commemorate.

It originated in commemorating the graves of those who died when fighting against the United States during the Civil War.

As to be expected, the actual origins were obscured by northern states, leading to some states to continue to remember Confederate Memorial Day. As noted by wikipedia - In their book, The Genesis of the Memorial Day Holiday in America, Bellware and Gardiner assert that the national Memorial Day holiday is a direct offshoot of the observance begun by the Ladies Memorial Association of Columbus, Georgia in 1866. In a few places, most notably Columbus, Mississippi and Macon, Georgia, Union graves were decorated during the first observance. The day was even referred to as Memorial Day by The Baltimore Sun on May 8, 1866, after the ladies organization that started it. The name Confederate Memorial Day was not used until the Northern observance was initiated in 1868.

That is the sort of trolling one would expect from Prior, whose oracle is wikipedia, which notes that such commemorations have an ancient history. But if one wants to date it in the U.S. to the Civil War period, then the funeral oration that truly originated the commemoration is Lincoln's Gettysburg Address. That bitter Southern rebels had to distinguish their commemoration by prefixing it with "Confederate" shows precisely the triumph of the North in determining its meaning.

The practice started in northern Virginia (not the modern meaning) in 1861 in Warrenton - before Lincoln's Gettysburg address, and before the South lost the war. The southern origins of decorating graves would be quite appropriate in the context of the current loss of life in the U.S. due to a virus. thepresidentshalloffame.com/?view=article&id=100:memorial-day

Some believe that an annual cemetery decoration practice began before the American Civil War and thus may reflect the real origin of the "memorial day" idea. Annual Decoration Days for particular cemeteries are still held on a Sunday in late spring or early summer in some rural areas of the American South, notably in the mountain areas. In cases involving a family graveyard where remote ancestors as well as those who were deceased more recently are buried, this may take on the character of an extended family reunion to which some people travel hundreds of miles. People gather, put flowers on graves and renew contacts with relatives and others. There often is a religious service and a picnic-like "dinner on the grounds," the traditional term for a potluck meal at a church.

On June 3, 1861, Warrenton, Virginia was the location of the first Civil War soldier's grave ever to be decorated, according to a Richmond Times-Dispatch newspaper article in 1906. In 1862, women in Savannah, Georgia decorated Confederate soldiers' graves according to the Savannah Republican. The 1863 cemetery dedication at Gettysburg, Pennsylvania, was a ceremony of commemoration at the graves of dead soldiers. On July 4, 1864, ladies decorated soldiers' graves according to local historians in Boalsburg, Pennsylvania. and Boalsburg promotes itself as the birthplace of Memorial Day.

As a (Re-)Founder, Lincoln and his Gettyburg Address has the superior claim, but that is a Straussian point lost on you.

Regardless, the main point is that the purpose of Memorial Day is to honor members of the military who died while serving their country. It is not some general commemoration of the dead.

As always prior is correct and typical Americans become emotional and childish when confronted with the truth.

Memorial Day is a uniquely American holiday in which morbidly obese mutt-Americans gorge themselves on fake German food in celebration of soldiers dying for slavery.

Later the holiday is updated to celebrate Americans dying in the tens of thousands to spread communism across the globe in 1945. Even later it is updated to celebrate Americans dying in the tens of thousands to incompetently murder peasant farmers in Asia, and then incompetently murder peasant farmers in the Middle East.

you seem to have ommitted ww1 & ww2 from your narrative

No I believe I mentioned spread communism

> Does it matter what their age is?

Does it make a difference to a three year old whether they lose their mother, or their grandmother, or their great-grandmother?

Numbers make it even starker. The difference at issue is sometimes whether a two year old loses their mother at age 3 instead of age 55, versus losing their great grandmother at age 3 instead of age 4.

". Those who died of Covid19 in Stockholm’s nursing homes had a life-remaining median somewhere in the range of 5 to 9 months."

This needs to be central in any VSL calculation.

Yes, they did not have a long time to live but they died from carelessness and that’s just wrong.
I believe in the Swedish model ( voluntary self distancing) but the vulnerable need to be protected.
I think in the West, lockdown or not, that’s the biggest failure.
Hong Kong didn’t have a single death in nursing homes and that’s not because of a general lockdown but because of the specific attention given to the problem with preventive measures:
Isolation outside the home even infected , infection officer in each home , tracing etc...
https://amp.theguardian.com/world/2020/may/19/mps-hear-why-hong-kong-had-no-covid-19-care-home-deaths

+1. The failure to get a handle on nursing homes continues and yet people are proposing even more extensive testing for the general population, most of which is of limited value.

VSL should be VSLY (Y = year) for COVID19.

The CBA would look much different.

Why not for every VLS calculation?

It has already been done throughout history before the math was there. "Women and children first (to the lifeboats)".

This could be a great development to apply to the science of VLS . . . To add the Y.

The “women and children first” ethos is memorialized by the 1852 wreck of the HMS Birkenhead, where the soldiers stood in ranks on deck while women and children were put into the few boats. The men died. It’s the origin of the term “Birkenhead drill”, and perhaps at least the formalization of the women and children first protocol.

Recall your Kipling: “To stand and be still, to the Birkenhead drill ...”

This is the weight on the other side of "care home deaths are terrible", yes they are but...

Cat is right, and there are terrible mistakes in protecting old people. At least in UK and US, these IMO stem from these delusional ideas about overwhelmed healthcare services pushed by certain flawed models and certain bloggers (usually centre-left who are always in a state of panic about government services), which led to fear of using "finite" resources for elderly, inaction of sheltering them. But on the other side of the ledger, if we care about years of healthy life expectancy, all deaths are not equal in that regard.

I'm glad they're including a bit more realism than the crowd that imply care home residents had 5 years of healthy life expectancy, and the like.

To quote Taleb, "Geronticide is the sign of moral decay" [1].

[1]: https://twitter.com/messages/239971600-303748916

Sweden lost the moral battle long ago.

A summer of the Young Gun variety is perhaps in order

And I’m still not seeing any reason why social distancing should be continued at a mass scale, when we can take useful and focused measures to save the people actually dying.

This “new normal” shit is ridiculous, and I’m appalled that people will so easily give up so much for a <0.5% decrease in probability of death this year. What then do you have to live for?

Brush up on your game theory and you'll know why.

re; 5-9 months: Let's say you "pay" one month's life expectancy for the whole population (100%), in the form of restricting activities entirely for the whole population, for the benefit of "saving" 7 months of let's say 25% of 3% of the population, at most (0.75% of the population).

In this case, you'd find you'd "paid" 30 days of life, to "save" 1.5, per capita. And this is before we get into the fact that what we'd be paying is days of life in the prime of life, and what we're saving is life in generally extremely ill health (often demented, confused, tired, in pain).

Now, this is a bit apples-to-oranges, because we know that lockdown countries did absolutely no *better-or-worse* than Sweden at protecting the elderly, and the only countries that did well were those were lucky to either keep the virus out entirely or keep it from gaining a foothold, whether they imposed lockdowns or not (and some did lockdown anyway, and some did not - New Zealand vs Australia). And measures probably prevented *some* deaths outside this group (even if not proportionately very many).

And we can reject this and say that it's all about preventing painful death, and not about savings months of life, which is a different calculus. Though, this suggests that pain meds may be a more proportionate solution.

But it gets us the flavour of what the topic at hand is, and the relative costs and scale. MR commentators, before this crisis, *used* to be able to talk about the trade-offs between very high costs of end-of-life care vs the actual benefits of that care. Perhaps they can do so again, some day.

I once heard an interview with the Swedish economist Per Bylund, who said that, with the ascendancy of the welfare state in Sweden, which has a very high level of benefits and entitlement services, many Swedes have renounced traditional family bonds, and that this has adversely affected both childrearing and care of the elderly -- with a disproportionate number of elderly in Sweden being placed in state run (or at least funded) institutions, and decreasing the rates at which elderly might have been cared for within the family home or even the community. This seems quite plausible to me. Blund is a free-marketer, so his comments were intended to be critical of the Swedish model -- he has a lot to say about cultural deterioration in Sweden due to the welfare state -- but my recollection is that his comments were ultimately of a factual nature, presenting data, etc. If anyone has further comments (or arguments against) this perspective, please give a response comment.

It's probably true to some small extent, but how many are we talking here?

People in care homes in Sweden or Italy or China are mostly people who can't live independently and need complex care that working families can't provide, while multi-generational elders in family homes in China or Italy are mostly people who'd simply live independently in Sweden, with family support. Look at the low expectations of remaining life expectancy noted in OP (this is not a healthy subpopulation).

There's usually a right-wing argument implicit that care homes are an intrusion by the market into the world of the family that's somehow caused by the decline of extended families. This is usually proposed by those on the right who would propose the family as an alternative form of extended support to the welfare state. But for the most part, it seems that they provide a unique role in sustaining life for elders who need constant care that is not already filled by extended family support, and for people who would simply die early without them (rather than some halcyon world where they were ministered to by younger female relatives and were perfectly fine).

There are some *retirement* homes where healthy older people live, but in Sweden or other such individualistic societies for instance, not many older people who can live unassisted would go into them.

Thanks for that thoughtful post -- good points worth exploring.

My recollection is that Per was contextualizing this as part of a number of trends: kids not receiving adequate attention (not necessarily in the traditional, conservative sense, but psychologically, because parents were developing narcissistic patterns) as well as (and this may have been his main point, but I really don't recall) high rates of unemployment and dependency. If I can find the interview I'll listen and will post the link one way or the other.

It's an interesting and important question: to what extent implementing extensive entitlements harms a significant portion of the beneficiaries, in terms of incentivizing dependence and other complex social and psychological responses. These questions are of course central to the UBI discussion, which is a different but in some ways related question, with a (potentially) different set of adverse consequences. I myself am ideologically -- by which I mean philosophically and ethically (in terms deontological / rights arguments) disposed against such programs -- but in the end I am also moved by consequentialist (e.g., utilitarian, Paretian) arguments so would like to understand those too in as specific a way as I can.

"There are really two sides (to) the elderly care Covid19 challenge: The vulnerability and frailty of those in nursing homes and the problem of nosocomial infection—that is, infection caused by contact with others involved in the elderly care experience." While the focus here is on assisted living facilities, the issue, nosocomial infection, applies to every place where social distancing is a challenge; indeed, we will likely find out soon enough the extent of nosocomial infection in, for example, restaurants. Since re-opening we are seeing just how reckless people can be. No, I'm not referring to the staff at restaurants, but the customers; self-centered American is an oxymoron. Stupid Americans following the lead of stupid American politicians. Just yesterday, Senator Scott of Florida repeatedly stated in an interview that Americans have a constitutional right to be stupid, and to practice their stupidity wherever and whenever they wish. https://www.politico.com/news/2020/05/24/rick-scott-church-bill-rights-275960

Stupid Americans following the lead of stupid American politicians

And chicken littles. Who are the stupid American Politicians following? The CDC? The experts? The models?

What did we learn? Don’t put recovering people into nursing homes. Vit D should be a standard Test in bloodwork.

If we’re lucky down the road, there’ll be a home test for Vit D.

"If we’re lucky down the road, there’ll be a home test for Vit D."
I've been taking 5,000 iu/day for many years. If we were lucky, everyone would.

A back-of-the envelope calculation of the economic benefit of Covid-19 response, using the numbers from Sweden, applied to the U.S., might go something like this. Worst case scenario, 2 million deaths. For nursing home deaths, assuming 9 months of life lost per victim, the value is generously 100k. For those not in nursing homes, assume a generous value of $2M. 70% nursing home deaths, 30% non-nursing home, gives you a total cost of about $1.3 T. The U.S. spent $3T in just one coronavirus bill. Economists can plug in numbers more reflective of the U.S. situation, but the results will not change the valence of the CBA. The lock-downs forced hundreds of millions of healthy people to make significant sacrifices to protect a small, high-risk population. The irony is that in many areas, that high-risk population was not, in fact, protected. Harrison Bergeron to the red courtesy phone please.

As a Swede with my wife living in a care home in a suburb north of Stockholm I would like to add some details. Where my wife is living about 2/3 of the personnel are born outside Sweden or have parents born outside Sweden. Most are from Africa or Middle East with an occasional Latin American. This is not necessarily a bad thing as they have grown up in societies where elderly persons are respected. But I would guess it presents some problems when introducing new routines and measures to prevent spread of a new type of virus infection. I have difficulty understanding some of the personnel.

For native Swedes social distancing is more or less the default setting. Not so for immigrants. In an article by an Assyrian, who discussed why proportionally more immigrants had died from the disease, he mentioned as examples that an extended family dinner could comprise 20 persons, a typical birthday party 100 persons and weddings and funerals several hundred persons. The death rate for persons from Somalia is 6 times the average Swedish death rate. Considering that there are few old persons in that group it is a high figure.

Judging from their age most of personnel at my wife’s care home have families with children living at home, children who go to school and play with other children. Many use public transport to get to work where there are many opportunities to get infected. I am not surprised that the infection has spread to so many care homes. I am more surprised that they have managed to keep the virus away from my wife’s care home.

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